A 5 YEAR AUDIT OF DENTAL IMPLANT TREATMENT AT THE UNIVERSITY OF

NAIROBI DENTAL HOSPITAL

MICHUGU CAROLINE WATIRI

V28/40067/2011

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A research proposal submitted to the School of Dental Sciences, University of Nairobi in

partial fulfillment of the degree of Bschelor of Dental Surgery (BDS)

DECLARATION

I, Michugu Caroline Watiri, declare that this research proposal is my own original work and has

neverbeen submitted before for any degree or examination in this or any other university

Signature rk~~i!!~ . iCf Ior I~OliDate .

SUPERVISORS APROV AL

We certify that this project has been submitted with our approval as supervisors:

INTERNAL SUPERVISOR

DR. B. N. MUA

BDS (NBI), MPH (NBI), MBA (St. Paul)

DEPARTMENT OF PERIODONTOLOGY/ PREVENTIVE AND COMMUNITY DENTISTRY,

SCHOOL OF DENTAL SCIENCES,

UNIVERSITY OF NAIROBI

Signature . Date ..J.~.I.Y/~LIEXTERNAL SUPERVISOR

DR. GAKONYO M. J

B.D.S (NBI), PGDipDent Implantology (Pretoria)

DEPARTMENT OF CONSERVATIVE AND PROSTHETIC DENTISTRY,

SCHOOL OF DENTAL SCIENCES,

UNIVERSITY OF NAIROBI.

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Signature .~ & . \ q \ g-} ::L '[) I '-fDate ; .

ii

TABLE OF CONTENT

DECLARATION i

TABLE OF CONTENT iii

ABBREVIATIONS v

ABSTRACT 1

CHAPTER 1: INTRODUCTION 3

CHAPTER 2: LITERATURE REVIEW 4

2.1 Surveys on implant therapy 4

2.2 Implantology as a multidisciplinary approach 4

2.3 Site preparation 4

2.4 Placement protocol followed 4

2.5 Causes of treatment failure 5

2.6 Possible complications 5

2.7 Causes of tooth loss and commonly lost teeth 5

3.1 Statement of research problem 6

3.2 Justification 6

3.3 Objectives 6

3.3.1 Main objective 6

To audit dental implant treatment at the UoNDH 6

3.3.2 Specific objectives .- 6

4. RESEARCH METHODOLOGy 7

4.1 Study Area 7

4.2 Study Population 7

4.3 Study Design 7

4.4 Variables 7

4.4.1 Socio-demographic variables 7

iii

4.4.2 Independent Variables 8

4.4.3 Dependent variables 8

4.5 Data 8

4.5.1 Data collection tools 8

4.5.2 Data analysis and presentation 8

4.5.3 Inclusion criteria and exclusion criteria 8

4.6 Sampling 9

4.6.1 Sampling unit 9

4.6.2 Sampling method 9

4.6.3 Sample size determination 9

4.7 Ethical Considerations 9

4.8 Control Of Errors And Bias : 9

4.9 Perceived Benefits 9

4.10 Limitations of the Study 9

5. PROPOSED BUDGET 10

5.1 Proposal Development Phase 10

5.4 Schedule Of Activities 11

REFERENCES 12

APPENDICES 13

APPENDIX 1: Data collection checklist 13

APPENDIX 2: Phone interview questions 14

APPENDIX 3: Letter to the ethical committee 14

iv

ABBREVIATIONS

BDS - Bachelor of Dental Surgery

KNH - Kenyatta National Hospital

UoNDH - University of Nairobi Dental Hospital

CBCT - Cone Beam Computed Tomography

GBR - Guided Bone Regeneration

MS EXCEL - Microsoft Excel

SPSS - Statistical Package for Social Sciences

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DEFINITION OF TERMS

Implant survival- An implant is said to have survived if it is still present in the mouth

irrespective of its status (Clinically or radiographically).

Treatment protocol- This is the timing of implant placement following extraction of a tooth. It

can either be immediate, early or delayed.

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ABSTRACT

Introduction

Dental implant therapy is now a popular procedure for replacement oflost teeth due to the highly

predictable outcomes with high survival and success rates. This form of treatment requires

comprehensive planning and precise surgical execution to be successful. Most of the information

available has been on implants done by experienced clinicians. Little data have been published on

the survival rates of implants placed in dental residency programs.

Aim

To audit dental implant treatment outcomes at the UoNDH between 2009 and 2013

Material and Methods

Study area: The study will be conducted in The University of Nairobi Dental School in Nairobi.

This is an institution located in the city of Nairobi

Study population: Patient records from the conservative, prosthetic and periodontology clinics

will be used as the primary source of data.

Study design: The study will be of a descriptive cross-sectional design.

Data management: A data collection checklist coupled with a phone interview shall be used. The

datawill be analyzed using SPSS and MS EXCEL. Descriptive statistics will be generated to

summarize the data collected and the results shall be presented in form of charts, tables and texts.

Ethical consideration

This study will be carried out after approval from Kenyatta National Hospital/ University of

Nairobi ethics, research and standard committee. Information collected will be treated

confidentially and will only be used for the purpose of the study.

Perceived benefits

The findings of this study will provide useful information in the teaching and policy formulation

on implant therapy at the UoNDH. Future studies will also be based on these findings regarding

the practice of implant therapy in the country.

Limitations

Some data may be unavailable due to inadequate documentation of some findings in the patient's

records.

2

CHAPTER1: INTRODUCTION

Implantdentistry is the art, science, and discipline concerned with the diagnosis, insertion of

titaniumimplants, and restoration of oral structures to restore the loss of contour, comfort,

function,esthetics, speech, and/or health ofthe partially or completely edentulous patient I. It has

become such a popular procedure for replacement oflost teeth that it is now regarded as the

standardof care for partial or full edentulous patients. It is now well documented that insertion of

dentalimplants into edentulous jaw bones to replace missing teeth, yields highly predictable

outcomeswith high survival and success rates 2,3.

Successof dental implant therapy depends on both local factors at the site of implantation and the

patient'ssystemic condition. In a recent systematic review ofliterature, uncontrolled diabetes,

recenthead and neck radiotherapy, smoking and biphosphonate use were found to be some of the

systemicpatient risk related factors for implant therapy 4. In the same review, local factors that

mayinfluence implant therapy were found to be: periodontitis related tooth loss and limiting local

anatomicalstructures. These factors are however not absolute contra-indications for placement of

dentalimplants.

In some cases pre-prosthetic procedures such as guided bone regeneration, onlay and inlay bone

grafts,bone splinting for ridge expansion, destruction osteogenesis and revascularized flaps are

doneto augment a deficient alveolar ridge and also to correct soft tissue discrepancies 5. There are

severalregenerative biomaterials available (auto grafts , allograft, xenografts, alloplasts and most

recentlygrowth factors) all with differing degrees of success in maintaining ridge dimensions 6.

Severalrisks and complications have been associated with dental implant therapy 7. Excessive

bleedingor nerve injury could occur during the surgical placement of the implant if proper

evaluationis not done before the procedure starts 8. Implant loss, peri-implant bone loss, peri

implantsoft tissue complications, esthetic/phonetic complications and mechanical failures 9

includingcrown fracture, implant fracture and screw or abutment loosening are some of the other

reportedcomplications 10.

3

CHAPTER 2: LITERATURE REVIEW

For a long time implant dentistry has been a fairly unexplored area but over the past few years its

gained popularity due to its predictability in producing excellent functional and aesthetic

outcomes. However, the full potential of implant dentistry is yet to be unveiled especially in

developing countries.

2.1 Survival rate surveys

Overall, the 5-year survival rate of implants is 95% and the lO-year survival rate is greater than

89% 9. Little information has been published on the survival rates of implants placed in dental

residency programs. In a study done at the University of Florida College of Dentistry, cumulative

implant survival was reported to be 98.2%. The implants were placed in dental residency program

and had follow-up varied from 6 months to 4 years after placement II.

2.2 Implantology as a multidisciplinary approach

A systematic review publication in the New Zeeland Dental Journal found that for a successful

implant therapy, a multidisciplinary approach should be adopted. This enables the general dentist

to come up with a plan of treatment that makes good use of the surgical, periodontal, orthodontic

and implant prosthetic techniques necessary to ensure a predictable implant outcome. In fact, the

literature showed that multidisciplinary approach is needed at implant placement stage to

determine the ideal placement site for the surgical, restorative and aesthetic needs of the patient 12.

2.3 Site preparation

To ensure optimal aesthetic implant rehabilitation, the following prerequisites are considered

essential: adequate bone volume (horizontal, vertical, and, contour), optimal implant position

(mesiodistal, apicocoronal, buccolingual,and angulation), stable and healthy periimplant soft

tissues, aesthetic soft tissues contours, and ideal emergence profile 13. Following tooth loss, the

alveolar ridge undergoes resorption in both horizontal and vertical dimensions and can lead to less

than optimal residual ridges for implant placement 14. Numerous ridge therapies to compensate for

the loss in height and width of the resultant ridge have been done and shown to ameliorate this

undesired yet unavoidable process 15.

2.4 Implant treatment protocol

A healed ridge provides the clinician with a more predictable site for placement of endosseous

implants. However, advances in contemporary implant therapy have led to development of

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improved implant surfaces for quicker healing after placement and also to an immediate

placement protocol 16,17. Systematic reviews show that early placement preserves bone height and

width of the ridge when compared with delayed protocol 18.

2.5 Causes of treatment failure

It has been shown that proper treatment planning and prosthetically driven placement of implants

leads to superior results in terms of function and aesthetics 19. When implants are placed in non-

ideal positions, several biomechanical complications can follow as a result of non-axial loading

which leads to occlusal overload. In a review of literature from January 1950 to July 2011,

biomechanical implant complications were shown to include peri-implant bone loss implant

fixture fracture, overdenture attachment fracture, abutment screw loosening, prosthetic framework

fracture and abutment screw loosening 10.

2.6 Possible complications

Implant therapy involves technique sensitive procedures and thus is prone to the complications

like any other surgical procedure. Treatment planning for dental implants involves the assessment

of patient-related risk factors prior to formulation of a treatment plan to prevent avoidable

complications 4. Radiological investigations of the jaw bones during dental implant therapy is a

vital step in treatment planning as it aids in determining the quantity, quality and angulations of

bone, selection of the potential implant sites, and in verification of absence of pathology.

Conventional radiographs (panoramic and periapical radiographs) only provide a two dimensional

view of a 3-dimensional object, and thus can lead to erroneous diagnosis 20. Diagnostic cone beam

computed tomography (CBCT) provides more accurate and precise views and also are helpful in

guided surgery and fabrication of accurate surgical stents 21,20.

2.7 Teeth loss and causes

Dental caries is the commonest cause of tooth loss, followed by periodontal disease with upper

and lower posteriors being the commonest teeth to be lost due to dental caries and periodontal

disease. Extractions as a form of traditional practice, orthodontic treatment and trauma accounted

for smaller percentages of total tooth loss. 22

5

3. STATEMENT OF THE RESEARCH PROBLEM, JUSTIFICATION OF STUDY AND

OBJECTIVES

3.1 Statement of research problem

Dental implants have become the most popular and reliable treatment option for restoring missing

teeth. At the university of Nairobi dental hospital, dental implants are done at the prosthodontic

and periodontology clinics. To evaluate the success and suitability of a treatment modality, it is a

common practice to go back to patient records and systematically review the procedures,

outcomes and clinical findings after some time at recall visits.

3.2 Justification

There is no known study at the UoNDH on the assessment of dental implant treatment, known to

the author. This study will thus form a baseline for future studies and help in policy formulation

regarding implant therapy in the school.

3.3 Objectives

3.3.1 Main objective

To audit dental implant treatment from June 2010 to June 2014 at the UoNDH

3.3.2 Specific objectives

a). To establish socio-economic demographics of patients treated with dental implants.

b). To establish a 5-year survival rate of the implant treatmtt.

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c). To determine the sites for implant placement.

d). To establish the ridge preparation procedures done before implant treatment.

e). To establish the timing of implant placement post-extraction.

f). To establish patient satisfaction. S5;(

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4. RESEARCH METHODOLOGY

4.1 Study Area

The study will be conducted in The University of Nairobi Dental School in Nairobi.

This is an institution located in the city of Nairobi. It is situated along Ralphe Bunche road

in Upper hill. It serves as a learning institution and offers dental services to the public as

the main referral for dental cases. It also offers private dental services in the Dental Plaza.

4.2 Study Population

Treatment notes of patients who have received implant treatment from the conservative,

prosthetic and periodontology clinics will be used as the primary source of data.

4.3 Study Design

The study will be of a descriptive cross-sectional design.

4.4 Variables

4.4.1 Socio-demographic variables

• Sex

• Age

• Occupation

• Level of education

• Area of residence

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IIII 4.4.3 Dependent variables

l • Status of the implant

• Patient satisfaction

4.4.2 Independent Variables

• Timing of implant placement post extraction.

• Investigation done

• Type of ridge therapy done

• Site of implant placement

4.5 Data

4.5.1 Data collection tools

• Review of patient records using a data collection checklist.

• Phone interview to find out patient satisfaction with the implant therapy.

\ 4.5.2 Data analysis and presentation

I The data will be analyzed using SPSS and MS EXCEL. Descriptive statistics will be generated to summarize

the data collected and the results shall be presented in form of charts, tables and texts.

I 4.5.3 Inclusion criteria and exclusion criteria

I4.5.3.1 Inclusion Criteria

1) Records of patients who have had dental implant treatment at the University of Nairobi Dental

Hospital.

2) Patients who have been followed up for not less than one year at the UoNDH.

4.5.3.2Exclusion Criteria

1. Records of patients who have had oral implants placed in other clinics other than in the University of

Nairobi Dental Hospital.

2. Patients who haven't had a one year follow up

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4.6 Sampling

4.6.1 Sampling unitTreatment record of a patient who has received dental implant treatment at the UoNDHbetween 2009 and

2013.

4.6.2 Sampling method

All records of patients who have received dental implant treatment at the UoNDH between 2009 and 2013

4.6.3 Sample size determination

All available treatment records patients who have received dental implant treatment at the UoNDH between

2009 and 2013 shall be used.

4.7 Ethical_Considerations

This study will be carried out after approval from Kenyatta National Hospital! University of Nairobi ethics,

research and standard committee. Information collected will be treated confidentially and will only be used for

the purpose of the study.

4.8 Control Of Errors And Bias

The data will be collected uniformly. Thereafter, the data will analyzed accurately thereby providing

accurate results.

4.9 Perceived Benefits

The findings of this study will provide useful information in the teaching and policy formulation on implant

therapy at the UoNDH. Future studies will also be based on these findings regarding the practice of implant

therapy in the country.

4.10 Limitations of the Study

Somedata may be unavailable due to inadequate documentation of some findings in the patient's records.

9

5. PROPOSED BUDGET

5.1 Proposal Development Phase

ITEM UNIT UNIT COST (KSH) TOTAL(KSH)

1. Stationery 200

2. Internet Services 20 hours 60 1200

3. Printing 150 5 750

4. Binding 3 60 180

5. Miscellaneous Cost 500

5.2 Data Collection Phase

Il\ 5.3 Report Writing Phase

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ITEM UNIT UNIT COST (KSH) TOTAL(KSH)

1. Printing 100 5 500

2. Stationery 200

ITEM UNIT UNIT COST (KSH) TOTAL

(KSH)

1. Draft Research project 400

2. Final report 400

3. Stationary 200

4. Printing and binding 1000

5. Miscellaneous cost 250

GRANDTOTAL 5680

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5.4 Schedule Of Activities

III

ACTIVITY DURATION

Proposal writing March - June 2014

Submission to Ethical Research Board June 2014

Data collection and Analysis September 2014

Report writing September - October 2014

Presentation October 2014

11

REFERENCES1. Frank la Mar. Implant dentistry today. J Oral Implantol 1997:44-46

2. Pjetursson, B. E., Bragger, U., Lang, N. P. & Zwahlen, M. Comparison of survival and complication

rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns

(SCs). Clin. Oral Imp Res 2007 1S(Suppl. 3): 97-113

3. Jung R. E., Pjetursson, B. E., Glauser, R., Zembic, A., Zwahlen, M. & Lang, N. P. A systematic review

of the 5-year survival and complication rates of implant-supported single crowns .. Clin. Oral Imp Res

200Sb 19: 119 -130.

4. G Liddelow, IKlineberg. Patient-related risk factors for implant therapy. A critique of pertinent

literature. Australian Dental Journal2011 56: 417-426.

5. Chiapasco M, Zaniboni M Boisco M. Augmentation procedures for deficient edentulous ridges with oral

implants. Clin. Oral Impl. Res. 2006 17 (Suppl. 2) : 136-159

6. Wang RE, Lang NP. New insights into ridge preservation after tooth extraction. Clin. Oral Implants Res.

2012 23(Suppl. 6) : 147-156.

7. Charles J. Goodcare, Guillermo Bernal, Kitichai Rungcharassaeng and Joseph, Y. K Kan. Clinical

complications with implants and implant prosthesis. J Prosthet Dent 2003 90 : 121-128

8. Flanagan D. Important arterial supply of the mandible, control of an arterial hemorrhage, and report of a

hemorrhagic incident. J Oral Implantol 2003 29: 165-173

9. Pjetursson, B.E., Tan, K., Lang, N.P., Bragger, u., Egger, M. & Zwahlen, M. A systematic review of the

survival and complication rates of fixed partial dentures (fpds) after an observation period of at least 5

years .. Clin. Oral Imp Res 2004 15: 625-642.

10. Fu, J.H., Hsu, Y.T. & Wang, H.L. Identifying occlusal overload and how to deal with it to avoid

marginal bone loss around implants. Eur J of Oral Implantol 2012 5(Suppl.): S91-S 103.

11. Mohamed A. Maksoud, Clifford B. Starr. Implant treatment in an urban general dentistry residency

program: a 4-year retrospective study. J Oral Implantol 200430(6) : 364-368.

12. Doreen Y. Ng, Andrew yc. Wong and Peter N. Liston. Multidisciplinary approach to implants: a

review. NZDJ2012:123-12S.

13. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a

mixed-longitudinal study covering 25 years. J Prosthet Dent. 1972 Feb;27(2):120-32.

14. Arau'jo M, Lindhe J.Dimensional ridge alterations following tooth extraction. An experimental study in

the dog. J Clin Periodontal 2005 32 : 212-218.

15.Ten Heggler JMAG, SIt DE, Van der Weijden GA. Effect of socket preservation therapies following

tooth extraction in non-molar regions in humans: a systematic review. Clin. Oral Imp Res 2011 22:779-

78S.

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16. Chen ST, Wilson TG, ,JR & Hemmerle CH. Immediate or early placement of implants following tooth

extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac

Implants 2004 (Supp1.24) : 186-217.

17. Hammerle, C.H., Chen, S.T. & Wilson, T.G., Jr . Consensus statements and recommended clinical

procedures regarding the placement of implants in extraction sockets Int J Oral Maxillofac Implants

(Suppl.19) : 26-28.

18. Sanz I, Garcia-Gargallo M,Herrera D, Martin C, Figuero E, Sanz M. Surgical protocols for early implant

placement in post-extraction sockets. A systematic review. Clin. Oral Imp Res 2012 23(Suppl. 5):

67-79.

19. Buser, D., Martin, W. & Belser, U.C. (2004) Optimizing esthetics for implant restorations in the anterior

maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004 19(5uppl.): 43-61.

20. Gintaras Juodzbalys, Marius Kubilius. Clinical and radiological classification of the jawbone anatomy

in endosseous dental implant treatment. J Oral Maxillofac Res 2013 (Apr-Jun) 4:1-17.

21. Aluned Ali Alhassani, Ali Saad Thafeed AlGhamdi. Inferior alveolar nerve injury in implant dentistry:

Diagnosis, causes, prevention and management. J Oral Implantol201 036(5): 401-407.

22. B.O Sanya, P.M Ng'anga and R.N Ng'anga. Causes and pattern of missing permanent teeth among

Kenyans. East. Afr. Med. J. 2004.

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APPENDICES

APPENDIX 1: Data collection checklist

AN AUDIT OF DENTAL IMPLANT TREATMENT AT THE UNIVERSITY OF NAIROBI DENTAL HOSPITAL

14

Patient Age Sex Level of Occupat Residence Site of Health status at Preoperative Anything complications Current Patient

no. educati ion placemen insertion investigation done before status of satisfied?

on t s placement? the

implant"

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Urban per Rural local s?,stemic Surgical Post Yes No,'~

urban ;:,.3 phase insertic \

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APPENDIX 2: Phone interview questionnaire

The following questions shall be asked during the phone interview:

1. Is the implant(s) still present in the mouth?

2. Do you have any problems regarding the implant(s)?

3. If YES, what is the problem?

4. Have you had any dental reviews done after the implant placement?

5. If YES, how many?

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15

UNIVERSITY OF NAIROBICOLLEGE OF HEALTH SCIENCESPOBOX 19676 Code 00202

Telegrams: varsity(254-020) 2726300 Ext 44355

KNH/UON-ERCEmail: uonknh_erc@uonbi.ac.ke

Website: www.uonbLac.keLink:www.uonbi.ac.ke/activitiesIKNHUoN

KENY ATT A NATIONAL HOSPITALPOBOX 20723 Code 00202Tel: 726300-9Fax: 725272

Telegrams: MEDSUP, Na~C?bL.,-~ ,~.....,

,'-.,-,\24th August /20:14

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Ref: KNH-ERC/UAl152

Michugu Caroline WatiriV28/40067/2011School of Dental SciencesUniversity of Nairobi

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Dear Caroline

Research Proposal - clearance -A 5 year audit of Dental implant treatment at theUniversity of Nairobi Dental Hospital (UP520/07/2014)

Your above proposal refers.

This is to inform you that permission has been granted by the KNH/UON-Ethics & Research Committee tocarry out research on study titled - A 5 year audit of Dental implant treatment at theUniversity of Nairobi Dental Hospital.

By a copy of this letter, I am requesting the relevant persons to accord you the professional supportand other materials that may be useful to your research.

NB: Use non-identifiable codes for the records accessed and NOT the actual file numbers.

PR . CHINDIASECRETARY, KNH/UON·ERC

Protect to discover

c.c. The Principal, College of Heaith Sciences, UONThe Deputy Director CS, KNHThe Chairperson, KNH/UoN-ERCAD, Health Information, KNHThe Dean, School of Dental Sciences, UoNSupervisors: Dr. B.N. Mua, Dr.Gakonyo M.J.